Pancreatic tumors in childhood: analysis of 13 cases

Unraveling the landscape of pediatric pancreatic tumors: Insights from Japan

Pediatric pancreatic tumors, though rare, pose significant diagnostic and management challenges. The recent, 22-year nationwide survey on pediatric pancreatic tumors in Japan by Makita et al offers valuable insights into this uncommon entity, revealing striking geographical variations and questioning current treatment paradigms. This editorial commentary analyzes the study's key findings, including the predominance of solid pseudopapillary neoplasms and their younger age of onset, which contrast sharply with Western data. It explores the implications for clinical practice and research, emphasizing the need for population-specific approaches to diagnosis and treatment. The revealed limited institutional experience and surgical management patterns prompt a reevaluation of optimal care delivery for these complex cases, suggesting benefits of centralizing healthcare services. Furthermore, the commentary advocates for international collaborative studies to elucidate the genetic, environmental, and lifestyle factors influencing the development and progression of pediatric pancreatic tumors across diverse populations. It also outlines future directions, calling for advancements in precision medicine and innovative care delivery models to improve global patient outcomes. Unraveling Makita et al's findings within the broader landscape of pediatric oncology can stimulate further research and clinical advancements in managing pancreatic and other rare tumors in children.

Surgical management of pancreatic neoplasms in children: a single-institution experience over 15 years

Introduction

Pancreatic neoplasms are rare among children and very few studies have reported on surgical outcomes for pediatric pancreatic neoplasms. Therefore, we aimed to describe patient and tumor characteristics and report on the surgical outcomes of pediatric pancreatic neoplasm.

Methods

In this retrospective single-center study, we reviewed and analyzed the data of patients who underwent surgery for pediatric pancreatic neoplasms at Severance Children's Hospital between January 2007 and December 2022. Clinical data including demographics, surgical procedures, and postoperative and long-term outcomes were evaluated.

Results

A total of 28 patients underwent surgical treatment for pancreatic neoplasms with a median age of 11.7 years (range: 0.4-17.8). The most common histological diagnosis among benign tumors was solid pseudopapillary neoplasm (SPN), which occurred in 20 patients (71.4%). This was followed by a mucinous cyst, nesidioblastosis, pseudocyst, duplication cyst, and benign cyst, each occurring in one patient (3.5%). Regarding malignant tumors, pancreatoblastoma, solid pseudopapillary carcinoma, and malignant pheochromocytoma were noted in one patient each (3.5%). Tumor locations included the head in 4 patients (14.2%), the body in 7 (25%), and the tail in 16 (57.1%), and was diffuse in 1 (3.5%). The most common surgical resection range was distal pancreatectomy, found in 22 patients (78.5%), followed by pylorus-preserving pancreaticoduodenectomy, found in 2 (7.2%); duodenum-preserving pancreatic resection, central pancreatectomy, tumor enucleation, and near-total pancreatectomy were performed in one patient each (3.5%). Overall, 4 patients developed grade B or C postoperative pancreatic fistulas, and 1 experienced postoperative mortality due to uncontrollable bleeding. The mean follow-up period was 6.1 years (range: 1-15.6 years), during which no significant impact on growth after surgery was detected. Among the 20 patients with SPN, tumor rupture occurred in 4 (20%), among whom 2 experienced tumor recurrences.

Conclusions

Histological diagnosis of benign tumors was predominant in this case series and various extents of surgical resection were performed. Surgical treatment for pediatric pancreatic neoplasms appears to be safe and effective. However, considering the long-term prognosis of these patients, it is essential to determine the appropriate extent of surgical resection based on the location of the tumor.

Solid pancreatic masses in children: A review of current evidence and clinical challenges

Pancreatic tumors in children are infrequently encountered in clinical practice. Their non-specific clinical presentation and overlapping imaging characteristics often make an accurate preoperative diagnosis difficult. Tumors are categorized as epithelial or non-epithelial, with epithelial tumors further classified as tumors of the exocrine or endocrine pancreas. Although both are tumors of the exocrine pancreas, solid pseudopapillary neoplasm is the most prevalent solid pancreatic tumor in children, while pancreatoblastoma is the most common malignant tumor. Insulinoma is the most common pediatric pancreatic tumor of the endocrine pancreas. Malignant tumors require a complete, often radical, surgical resection. However, pancreatic parenchyma-sparing surgical procedures are utilized for benign tumors and low-grade malignancy to preserve gland function. This review will discuss the epidemiology, pathophysiology, clinical and diagnostic characteristics, and management options associated with both common and rare solid pancreatic masses in children. We will also discuss current challenges encountered in their evaluation and treatment.

Pancreatoblastoma in children: EXPeRT/PARTNER diagnostic and therapeutic recommendations

Pancreatoblastoma (PBL) is a rare malignant epithelial neoplasm that affects typically young children. Signs related to advanced upper-abdominal tumor accompanied by elevated serum α-fetoprotein levels in a young child suggest PBL, however histopathological confirmation is mandatory. The mainstay of the treatment is a complete surgical resection. Unresectable and/or metastatic PBL may become amenable to complete delayed surgery after neoadjuvant chemotherapy. This manuscript presents the international consensus recommendations for the diagnosis and treatment of children with PBL, established by the European Cooperative Study Group for Pediatric Rare Tumors (EXPeRT) within the EU-funded PARTNER (Paediatric Rare Tumors Network - European Registry) project.

Pancreatectomies for pediatric pancreatic tumors: A single institute experience from 2007 to 2018

BACKGROUND

To investigate the safety, feasibility, and complications of pancreatectomies for pediatric pancreatic tumors.

METHODS

The medical records of pancreatectomy patients from January 2007 to January 2018 were retrospectively analyzed for perioperative factors and complications. Patients were divided into pancreatic head (n = 43), body (n = 18) and tail (n = 43) groups.

RESULTS

Seventy-two girls and 32 boys (median age 10 years at diagnosis, range: 0-15 years) were enrolled and had solid pseudopapillary tumors (n = 73), pancreatoblastoma (n = 19), neuroendocrine tumors (n = 9), and others. Primary surgical procedures included pylorus-preserving pancreaticoduodenectomy (n = 10) and distal pancreatectomy with splenectomy (n = 4), and organ-sparing resection procedures included duodenum-preserving pancreas head resection (n = 25), middle segmental pancreatic resection (n = 15), spleen-preserving distal pancreatectomy (n = 37) and local enucleation (n = 13), with a median blood loss of 20 cm³ (range: 10-300 cm³). Short-term complications included pancreatic fistula (35.6%), bile leakage (2.9%), intraabdominal infection (21.2%), delayed gastric emptying (23.1%), and postpancreatectomy hemorrhage (5.8%). After a median follow-up of 38 months (range: 3-143 months), 94 patients (90.4%) were alive without tumor recurrence, 2 were alive after tumor recurrence, 1 pancreatoblastoma patient died from tumor recurrence, and 7 were lost to follow-up. Only 14 patients (14/96, 14.6%) had long-term complications at the outpatient follow-up.

CONCLUSIONS

Surgical resection was the main treatment for pancreatic tumors. Organ-sparing resection procedures led to good long-term results for pediatric pancreatic tumors, even if these procedures could cause a relatively high incidence of short-term complications (especially pancreatic fistula and postpancreatectomy hemorrhage).

LEVEL OF EVIDENCE

Level IV.

Persistent Hypoglycemia in Seven-year-old Saudi Child: A Case Report

Hypoglycemia is a frequent problem in infants and children, causing a significant dilemma to reach the correct diagnosis and perform the appropriate management. Congenital hyperinsulinism is the most common cause of hypoglycemic hyperinsulinemia in infants and is due to beta-cell hyperplasia caused by genetic defects. This is a well-known genetically and clinically heterogeneous condition causing severe hypoglycemia in infants. Insulin-secreting tumors (insulinoma) are rare findings during childhood. In contrast, insulinoma is the most common form of endogenous hypoglycemic hyperinsulinemia in the adult population. Here we present a successful diagnosis and treatment of a nine-year-old Saudi child who presented for the first time with severe episodes of hypoglycemia at age seven. Critical samples at the time of hypoglycemia confirmed the associated hyperinsulinemia state. Initially, the child responded well to anti-insulin medications at small doses, but with time the disease became progressive in severity requiring a high dose of anti-insulin medications, frequent glucagon injections, and hospital admission for intravenous dextrose infusion. After two years of seeking therapy in many hospitals, the final diagnosis was confirmed to be an insulinoma, which was removed surgically, resulting in a complete cure and full recovery. Here we report the first published case of insulinoma in a young child aged < 15 years old in Saudi Arabia, their disease course, final diagnostic steps, and curative therapy. We conclude that hypoglycemia in children is challenging in terms of diagnosis and management. Although insulinoma is very rare in children, it requires significant time and effort by a pediatrician, pediatric endocrinologist, patients, and parents to reach the final diagnosis and carefully preserve the integrity of the neurological state of those children.

Is cancer latency an outdated concept? Lessons from chronic myeloid leukemia

Our concept of cancer latency, the interval from when a cancer starts until it is diagnosed, has changed dramatically. A prior widely-used definition was the interval between an exposure to a cancer-causing substance and cancer diagnosis. However, this definition does not accurately reflect current knowledge of how most cancers develop assuming, mostly incorrectly, one exposure is the sole cause of a cancer, ignoring the possibility the cancer being considered would have developed anyway but that the exposure accelerated cancer development and eliding the randomness in when a cancer is diagnosed. We show, using chronic myeloid leukaemia as a model, that defining cancer latency is not as simple as it once seemed. It is difficult or impossible to know at which event or mutation to start to clock to measure cancer latency. It is equally difficult to know when to stop the clock given the stochastic nature of when cancers are diagnosed. Importantly, even in genetically-identical twins with the same driver mutation intervals to develop cancer vary substantially. And we discuss other confonders. Clearly we need a new definition of cancer latency or we need to abandon the concept of cancer latency in the modern era of cancer biology.

Prognostic analysis of very early onset pancreatic cancer: a population-based analysis

BACKGROUND

We aimed to use competing risk model to assess whether very early onset pancreatic cancer (VEOPC ) (<45 years) had a worse prognosis than older pancreatic cancer (PC) patients, and to build a competing risk nomogram for predicting the risk of death of VEOPC.

METHODS

We selected pancreatic adenocarcinoma (PDAC) patients as our cohort from the Surveillance, Epidemiology, and End Results (SEER) database. The impact of cancer specific death was estimated by competing risk analysis. Multivariate Fine-Gray regression for proportional hazards modeling of the subdistribution hazard (SH) model based nomogram was constructed, which was internally validated by discrimination and calibration with 1,000 bootstraps.

RESULTS

Our cohort included 1,386 VEOPC patients and 53,940 older patients. We observed that in unresectablePDAC patients, VEOPC had better cancer specific survival (CSS) than each older group (45-59 years, 60-69 years, 70-79 years and >79 years). There was no significant prognostic difference between VEOPC and each older group in resectablePDAC. Our competing nomogram showed well discrimination and calibration by internal validation.

CONCLUSION

For unresectable PDAC patients, VEOPC had better CSS than older patients. Our competing risk nomogram might be an easy-to-use tool for the specific death prediction of VEOPC patients with PDAC.

Pancreatic islet cell tumors in adolescents and young adults

BACKGROUND

Pancreatic islet cell tumors are rare in adolescents, and most studies published to date focus on older patients. We utilized a national database to describe the histology and clinical pattern of pancreatic islet cell tumors in adolescent and young adult (AYA) patients, and to compare AYAs to older adults. We hypothesized that AYAs with pancreatic islet cell tumors would have better overall survival.

METHODS

The National Cancer Data Base (NCDB, 1998-2012) was queried for AYA patients (15-39 years) with a pancreatic islet cell tumor diagnosis. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted and compared to adults (≥40 years).

RESULTS

383 patients (56.4% female, 65% non-Hispanic Whites) were identified, with a median age of 27 (IQR 16-34) years. Islet cell carcinoma was the most common histology. Of patients with known stage of disease, 49% presented with early stage (I or II). Seventy percent of patients underwent surgical resection, including local excision 44%, Whipple procedure 37.5%, or total pancreatectomy 19%. Chemotherapy was utilized in 27% and radiotherapy in 7%. All-cause mortality was 36%. AYA patients underwent more extensive resections (p = 0.001) and had lower mortality rates (p < 0.001), with no differences in tumor stage or use of adjuvant therapies, when compared to adults.

CONCLUSIONS

AYA patients with pancreatic islet cell tumors had comparable utilization of adjuvant therapies but underwent more extensive resections and demonstrated a higher overall survival rate than adult counterparts. Further investigation into approaches to earlier diagnosis and tailoring of multimodality therapy of these neoplasms in the AYA population is needed.

LEVELS OF EVIDENCE

Prognostic Study, Level II - retrospective study.

Whipple's Pancreaticoduodenectomy in Pediatric Patients: An Experience from a Tertiary Care Center

Purpose:

Whipple's pancreaticoduodenectomy (WPD) is rarely required in children. However, WPD is the only option with pathologies involving the head of the pancreas requiring surgical excision. The objective of our study was to review our experience with WPD performed on children.

Materials and Methods:

A retrospective analysis of case records was conducted on all patients <18 years of age, who underwent WPD at our center over the last 20 years. Data regarding demographics, signs, and symptoms at presentation, diagnostic imaging and procedures, pathologic reports, surgical and medical treatment, and follow-up were collected to study the indications and safety and outcomes of WPD in children.

Results:

Five patients had been planned for a WPD during the study (1995–2015); but in one patient, the procedure was abandoned, the rest four patients formed the study group. Male to female ratio was 3:1. Median age at the time of surgery was 9 years (11 months–12 years). The most common presentation was obstructive jaundice (50%, 2/4). Radiological imaging was able to accurately predict the surgical procedure required in all except one case. The mean operating time was 205 min (180–240 min). There were no intraoperative complications. The mean intraoperative blood loss was 85 mL (20–150 mL). The youngest patient requiring WPD was an 11-month-old child. Oral feeding was established by the 7^th postoperative day (range 5–7 days) in all cases. There were no cases of anastomotic leak or pancreatic or jejunal fistulae. One patient developed features of subacute intestinal obstruction after discharge and required re-exploration. There was no intra- or post-operative mortality.

Conclusion:

WPD is safe and efficacious procedure in a selected group of children. The overall efficacy of surgical treatment combined with the relatively low severity of complications leads us to recommend WPD in children when indicated.

Solid pseudopapillary and malignant pancreatic tumors in childhood: A systematic review and evidence quality assessment

A systematic review of 32 studies reporting on 489 children with pancreatic tumors was performed. The most prevalent histologic subtype was solid pseudopapillary tumor (SPT) (61.3%). Pancreaticoduodenectomy was the most commonly performed operation (48%). Neoadjuvant chemo/radiotherapy was utilized in 3.9, 36.2, 25, and 27.8% of patients with SPTs, pancreatoblastomas (PBLs), neuroendocrine tumors, and exocrine carcinomas, respectively. Adjuvant chemotherapy (75.6%) and radiation (34%) were most commonly utilized in PBLs. All-cause mortality was highest in exocrine carcinomas (50%). Overall, 98.8% of patients with SPTs survived. PBL exhibited the highest recurrence rate (14.7%) within a mean of 23.5 months.

Robotic-assisted, spleen-preserving distal pancreatectomy for a solid pseudopapillary tumour in a pediatric patient: a case report and review of the literature

Solid pseudopapillary tumour is a rare carcinoma of the pancreas with low-grade malignant potential that typically presents in females in their third decade. The tumour most commonly occurs in the tail of the pancreas, although any site can be affected. Surgical resection is the standard treatment and offers an excellent prognosis. Robotic-assisted laparoscopic surgery is an emerging technique for the treatment of pancreatic neoplasms. We report a case of a 17-year-old female with acute onset abdominal pain who was found to have a mass in the distal pancreas. A robotic-assisted laparoscopic distal pancreatectomy with spleen preservation was successfully performed, its first reported use in a pediatric patient. The patient had an uncomplicated recovery. The robotic approach can be considered for younger patients presenting with a solid pseudopapillary tumour in the distal pancreas.

A population-based analysis of a rare oncologic entity: Malignant pancreatic tumors in children

PURPOSE

To examine the clinicopathological characteristics and prognosis of pediatric patients with malignant pancreatic tumors in a population-based cohort.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify all pediatric patients with malignant pancreatic tumors, diagnosed between 1973 and 2013. Kaplan-Meier analysis was performed to determine median and five-year overall survival (OS) rates. Univariate survival analysis was executed using the log-rank test. Cox proportional hazards model was used to identify variables independently associated with mortality.

RESULTS

A total of 114 patients with pancreatic malignancies were identified. Median patient age was 16years and the majority of patients were white (64%) females (61.4%). The most prevalent histologic subtype was neuroendocrine tumors (35.1%), whereas pancreatoblastoma was more common during the first decade of life (P<0.001). Distant metastases were noted in 41.7% of the patients, while 33.3% and 25% had localized and regional disease respectively. Five-year OS rates were 77%, 66.4% and 64.8% for patients with pancreatoblastoma, neuroendocrine and epithelial tumors respectively. No death was observed in the solid pseudopapillary tumor group. Only history of having cancer-directed surgery (CDS) was significantly associated with lower overall mortality (HR: 5.1, 95% CI: 2.1, 12.4).

CONCLUSION

Pancreatic malignancies are rare in children. Their prognosis is variable and only CDS was independently associated with superior survival.

EVIDENCE RATING/CLASSIFICATION

Prognosis study, Level II.

Insulinoma masquerading as a loss of consciousness in a teenage girl: case report and literature review

BACKGROUND

Hypoglycemia due to a pancreatic beta cell neoplasm - insulinoma, is uncommon with only a few cases described. We report on a previously healthy 15-year-old Hispanic female with insulinoma who presented with a loss of consciousness due to hypoglycemia unawareness.

CASE PRESENTATION

EM was first brought to the emergency department (ED) after she was found unresponsive at home with point of care (POC) glucose of 29 mg/dL(1.6 mmol/L) documented by emergency medical services (EMS) upon arrival. After treatment with dextrose and normal laboratory evaluation, including complete blood count, basal metabolic profile and urine drug screen, she was sent home with recommendations to follow-up the next day with an endocrinologist. Due to insurance issues, the family did not keep the appointment. Two days later, she returned to the ED with POC of 19 mg/dL (1.05 mmol/L). Detailed history review identified vague fatigue, excessive sleepiness, poor oral intake and weight gain for a 2-3 month period and no suspicion for drug, alcohol or prescription medication abuse. Family history of multiple endocrine neoplasia was negative. Physical examination revealed mild acanthosis nigricans and a body mass index of 32.8 kg/m² (98th percentile). Laboratory evaluation showed elevated insulin with low cortisol and growth hormone levels at the time of hypoglycemia. Abdominal magnetic resonance imaging revealed a pancreatic mass, also supported by ultrasound, computed tomography and positron emission tomography scans. The patient underwent a partial pancreatectomy with removal of a well-circumscribed insulinoma from the anterior-superior aspect of the pancreatic neck confirmed by histology. Hypoglycemia resolved post-operatively and she remained euglycemic during a 48-h cure fast. At her 3-month follow-up visit, she had no symptoms of hypoglycemia.

CONCLUSION

Documented hypoglycemia in an otherwise healthy adolescent should be fully investigated before discharging a patient. Even a short duration of symptoms should prompt, in-depth diagnostic evaluations to rule out a potentially life threatening diagnosis of insulinoma.

Pancreatic solitary fibrous tumor in a toddler managed by pancreaticoduodenectomy: a case report and review of the literature

Solitary fibrous tumor (SFT) of the pancreas is rare, with 15 adult cases reported in the English literature. We described a 14-month-old boy who presented with obstructive jaundice. Dominantly elevated serum CA19-9 was detected. Imaging studies revealed a well-circumscribed, solid mass in the pancreatic head. A pancreaticoduodenectomy (child procedure) was performed using Shen’s anastomosis technique. After resection of the tumor, liver function and serum tumor markers normalized and clinical signs receded. The boy was disease free after a follow-up of 12 months. Histological examination showed the tumor consisted of “patternless pattern” arranged spindle tumor cells and keloid-like hyalinized collagen. Immunohistochemical staining was positive for CD34 and vimentin. Mutation analysis of CTNNB1 was negative. To the best of our knowledge, our patient was the first case of pancreatic SFT in a pediatric population. SFT should be considered in differential diagnosis when confronted with a pancreatic tumor in children. Complete resection should be meticulously pursued.

Radical resection and enucleation in Chinese adolescents with pancreatic tumors: A 15-year case series

Pancreatic tumors rarely occur in adolescents, and the appropriateness of radical resection for these patients remains controversial.Medical records were retrospectively reviewed for patients younger than 19 years who underwent radical resection or limited resection (enucleation) between 2000 and 2015. Patient demographics, clinical characteristics, operative details, growth, and survival were analyzed.During the study period, 11 adolescents (mean age, 16.18 years; standard deviation, 1.99; interquartile range, 15.0-18.0) underwent radical resection (n = 7) or enucleation (n = 4) to treat solid pseudopapillary tumors (n = 5), pancreatic neuroendocrine tumors (n = 5), or pancreatic ductal adenocarcinoma (n = 1). None of the 7 patients who underwent radical resection experienced recurrence or serious complications, while 3 of 4 patients who underwent enucleation experienced recurrence (P = 0.02). Recurrence-free survival was slightly longer in patients who underwent radical resection, and this procedure did not appear to affect adolescent growth and development.Radical resection might be safe and effective for adolescents with pancreatic tumors.

Pancreatic surgery for tumors in children and adolescents

PURPOSE

Pancreatic neoplasms are uncommon in children. This study sought to analyze the clinical and pathological features of surgically resected pancreatic tumors in children and discuss management strategies.

METHODS

We conducted a retrospective review of patients ≤21 years with pancreatic neoplasms who underwent surgery at a single institution between 1995 and 2015.

RESULTS

Nineteen patients were identified with a median age at operation of 16.6 years (IQR 13.5-18.9). The most common histology was solid pseudopapillary neoplasm (SPN) (n = 13), followed by pancreatic neuroendocrine tumor (n = 3), serous cystadenoma (n = 2) and pancreatoblastoma (n = 1). Operative procedures included formal pancreatectomy (n = 17), enucleation (n = 1) and central pancreatectomy (n = 1). SPNs were noninvasive in all but one case with perineural, vascular and lymph node involvement. Seventeen patients (89.5 %) are currently alive and disease free at a median follow-up of 5.7 (IQR 3.7-10.9) years. Two patients died: one with metastatic insulinoma and another with SPN who developed peritoneal carcinomatosis secondary to a concurrent rectal adenocarcinoma.

CONCLUSIONS

Pediatric pancreatic tumors are a heterogeneous group of neoplastic lesions for which surgery can be curative. SPN is the most common histology, is characterized by low malignant potential and in selected cases can be safely and effectively treated with a tissue-sparing resection and minimally invasive approach.

Solid Pseudopapillary Neoplasm of Pancreas; A Case Series and Review Literature

BACKGROUND

Information regarding solid pseudopapillary neoplasm (SPN) of the pancreas is limited in Iran. We aimed to review the clinicocytopathological features and follow-up of patients with SPN of pancreas who were diagnosed in a single center in Iran.

METHODS

Seven patients with SPN of the pancreas were diagnosed during January 2010 to March 2015 at the Digestive Disease Research Institute of Tehran University of Medical Sciences. The patients were reviewed prospectively.

RESULTS

Six out of the 7 patients were female and the mean age of all the patients was 29.4 years ranging from 15 to 61 years. The most common clinical presentation was nonspecific abdominal pain (N=6). The tumors were located mostly in head and neck of the pancreas. SPN was diagnosed in all patients by fine needle aspiration through endosonography (EUS-FNA). All patients underwent surgery. Histological findings of surgical tissues were consistent with EUS-FNA. The postoperative follow-up period of about 14 months was uneventful.

CONCLUSION

SPN of the pancreas is a rare pancreatic tumor which affects primarily young women. EUS-guided FNA could play an important role in preoperative diagnosis of SPN of the pancreas.

Pancreatic tumours in children: diagnosis, treatment and outcome

PURPOSE

Pancreatic tumours in children are exceedingly rare and as a result constitute a diagnostic and therapeutic challenge to paediatric surgeons. We reviewed our experience with these rare entities.

METHODS

Retrospective single institution study on all paediatric pancreatic tumours over a period of 38 years (1973-2011) and literature review. We recorded data relating to the clinical features at presentation, diagnostic evaluation, treatment and outcome.

RESULTS

Fourteen patients were identified (eight male). The most common symptoms at presentation were abdominal pain, anorexia and vomiting. Two cases were discovered incidentally. There were 12 primary and 2 metastatic tumours. Tumour types were solid pseudopapillary neoplasm (n = 6), insulinoma (n = 3), pancreatoblastoma (n = 1), congenital pancreatic cyst (n = 1), Burkitt lymphoma of the pancreas (n = 1) and metastatic lesions of other primary tumours (n = 2). Twelve were treated with surgical resection including 2 laparoscopically. Post-surgical complications included acute pancreatitis (n = 2) and pancreatic pseudocyst (n = 2). There was one death from a metastatic tumour and treatment is ongoing in one patient. The remainder has survived.

CONCLUSION

Paediatric pancreatic tumours are rare entities and are usually benign. Clinical symptoms are often non-specific and presentation may be late due to tumour inactivity in case of endocrine neoplasms. For most tumours, surgical resection is the optimal treatment which may be successfully performed laparoscopically when the lesion is in the body or tail of the pancreas. Long-term outcome is generally good.

Comparison of abdominal ultrasonographic findings with endoscopic ultrasonographic findings of solid pseudopapillary neoplasms of the pancreas

To compare abdominal ultrasonographic (AU) findings with endoscopic ultrasonographic (EUS) findings of solid pseudopapillary neoplasm (SPN) of the pancreas, 13 patients (male-to-female ratio, 3:10; mean age, 36 years) with surgically proven SPN who underwent both preoperative AU and EUS were included in the study. Ultrasonographic findings of the 2 modalities were compared according to internal echogenicity, calcification, demarcation, internal septum, and main pancreatic duct dilatation. Nine cases showed hypoechogenicity on both AU and EUS. The remaining 4 cases showed different echogenicity on both modalities as follows: hypoechogenicity (n = 2) and isoechogenicity (n = 2) on AU; and hyperechogenicity (n = 1), poor visualization of internal architecture due to dense rim calcification (n = 2), and isoechogenicity (n = 1) on EUS. In 2 cases with dense rim calcification, evaluation of the internal contents was more difficult on EUS compared with AU. In addition, central punctate calcifications of 2 cases were well visualized on both AU and EUS, but the 1 case of peripheral calcification was only seen on EUS. All cases showed good demarcation without main pancreatic ductal dilatation or internal septa. Endoscopic ultrasonography was superior to AU for the evaluation of internal echogenicity of pancreatic SPN; however, AU was superior at evaluating larger tumors and tumors with dense rim calcification.

Insulinoma: only in adults?-case reports and literature review

Insulinomas first presenting as refractory seizure disorders are well documented in adulthood but rarely found in children. Only a few cases of childhood insulinoma have been reported so far. We report on two adolescents with hyperinsulinaemic hypoglycaemia, initially misdiagnosed as epilepsy and migraine accompagnée, and compare those to other cases published. Localization of insulinoma was challenging and, in one patient, angiography with selective arterial calcium stimulation and hepatic venous sampling in addition to CT and MRI was necessary. In these patients, long-term recovery was achieved by laparoscopic distal pancreatic resection in one and by conventional enucleation in the pancreatic head in the second patient. In contrast to adults, macrosomy and a decrease in school performance were the main symptoms and, during fasting, impaired cognitive function occurred after a relatively short period and at a higher glucose threshold or lower insulin/glucose ratio, respectively. Neuroglycopenic signs may be attributed to behaviour abnormalities or seizure disorders but in children and adolescents may already be caused by insulinoma. In these cases, timely diagnosis as well as tumour resection ensure long-term cure.

Pancreaticoduodenectomy for malignancies in children

PURPOSE

Malignant tumors of the common bile duct or of the pancreas head are uncommon in childhood [Perez EA, Gutierrez JC, Koniaris LG, Neville HL, Thompson WR, Sola JE. Malignant pancreatic tumors: incidence and outcome in 58 pediatric patients. J Pediatr Surg. 2009; Jan; 44 (1): 197-203]. With radical surgery being the standard cure for nonmetastatic diseases, pancreaticoduodenectomy (PD) is the best choice when the tumor is localized in the head of the pancreas, or in the lower portion of the common bile duct. The purpose of the present study is to describe five consecutive children managed by PD, and reviewing the particular aspects and results of this rare procedure in children.

METHODS

Between 2007 and 2010, five patients (median age: 7 years) underwent PD for nonmetastatic malignant tumors. In two cases, PD was performed en bloc with a right hepatectomy in order to achieve the radical resection of a recurrent biliary sarcoma. Four patients benefited from a "pylorus-preserving" PD procedure. In two patients, resection of the portal vein and vascular reconstruction was performed, and in one case, an extended resection of the biliary ductal system was necessary.

RESULTS

All resection margins were clear. The postoperative course was uneventful, with no pancreatic or biliary leakage in all of the patients. Oral refeeding was achieved by the eighth postoperative day. In two cases, a late revision of pancreatic-jejunal anastomosis was performed because of mild steatorrea and a suspected anastomotic stricture. Two of the patients, who were subsequently operated on second hand, for biliary sarcoma, died from the recurrence; while three of the others, with pancreatic malignancies, are alive and well, with a good functional outcome.

CONCLUSIONS

Surgical resection is the treatment of choice for tumors of the pancreatic head area. In the absence of regional or metastatic extension, the radicality of primary intervention is associated with favorable outcomes. Good functionality results were observed after the PD was limited to the head of the pancreas and subject to pylorus-preserving techniques.

The surgical management of insulinomas in children

PURPOSE

Insulinomas are rare pediatric tumors for which optimal localization studies and management remain undetermined. We present our experience with surgical management of insulinomas during childhood.

METHODS

A retrospective review was performed of patients who underwent surgical management for an insulinoma from 1999 to 2012.

RESULTS

The study included eight patients. Preoperative localization was successful with abdominal ultrasound, abdominal CT, endoscopic ultrasound, or MRI in only 20%, 28.6%, 40%, and 50% of patients, respectively. Octreotide scan was non-diagnostic in 4 patients. For diagnostic failure, selective utilization of 18-Fluoro-DOPA PET/CT scanning, arterial stimulation/venous sampling, or transhepatic portal venous sampling were successful in insulinoma localization. Intraoperatively, all lesions were identified by palpation or with the assistance of intraoperative ultrasound. Surgical resection using pancreas sparing techniques (enucleation or distal pancreatectomy) resulted in a cure in all patients. Postoperative complications included a pancreatic fistula in two patients and an additional missed insulinoma in a patient with MEN-1 requiring successful reoperation.

CONCLUSIONS

Preoperative tumor localization may require many imaging modalities to avoid unsuccessful blind pancreatectomy. Intraoperative palpation with the assistance of ultrasound offers a reliable method to precisely locate the insulinoma. Complete surgical resection results in a cure. Recurrent symptoms warrant evaluation for additional lesions.

Lymphoepithelial cyst of the pancreas in female children--report of two cases

Lymphoepithelial cyst (LEC) of the pancreas is almost always reported as a case report or in small series mostly in male adult patients with vague clinical manifestations and difficult pre-operative diagnosis. Between the years 2007 and 2012, two female children with LEC of the pancreas were operated on at the Children's Surgical Unit of Murtala Mohammad Specialist Hospital, Kano in northern Nigeria. Satisfactory outcomes were achieved after distal pancreatectomy and splenectomy in one and a Whipple procedure in the other. This benign lesion of the pancreas should be considered in the differential diagnosis of cystic lesions of the pancreas in children.

Clinical analysis of childhood pancreatoblastoma arising from the tail of the pancreas

Pancreatoblastoma is a rare pancreatic tumor. In this study, 3 cases of childhood pancreatoblastoma that arise from the tail of the pancreas were reported. Abdominal pain and vomiting were observed in 1 case considering the huge size of the tumor. The other 2 patients, who were previously well, complained of a mass in the abdomen after a casual physical examination. Elevated serum α-fetoprotein levels were noted in all cases. Imaging findings indicated a well-defined heterogeneous large mass in the left retroperitoneal space. Exploratory laparotomy revealed a large mass, arising from the tail of the pancreas. Surgery alone with complete excision of the masses was performed. Immunohistochemical staining showed that only α-fetoprotein was positive in all cases. All of these 3 cases have a good outcome in the follow-up without adjuvant chemotherapy. These data suggest that the diagnosis of pancreatoblastoma is difficult and should be suspected at palpation of an abdominal mass. α-Fetoprotein may serve as a tumor marker for preoperative diagnosis and postoperative recurrence. Pancreatoblastoma arising from the tail of the pancreas is a curable tumor, and adjuvant chemotherapy may not be necessary if the tumor can be excised completely.

Tratamento cirúrgico dos insulinomas do pâncreas

RACIONAL - O insulinoma do pâncreas é neoplasia neuroendócrina proveniente das células beta das ilhotas pancreáticas. Apesar de rara, é a neoplasia endócrina pancreática mais comum, com cerca de quatro casos por milhão de pessoas. O tratamento preferencial dos insulinomas é cirúrgico. OBJETIVO - Analisar as características clínicas, epidemiológicas, cirúrgicas e anatomopatológicas dos pacientes tratados na última década em dois serviços. MÉTODOS - Foram revisados retrospectivamente os prontuários dos pacientes submetidos à cirurgia para tratamento de insulinoma no período de 1999 a 2011. Dados demográficos, tipo e duração dos sintomas, associação ou não à síndrome endócrina e exames diagnósticos foram obtidos dos registros de prontuários. Analisaram-se, também, o método cirúrgico, achados intra-operatórios e complicações imediatas e tardias. RESULTADOS - Dezesseis pacientes com diagnóstico de insulinoma foram submetidos ao tratamento cirúrgico. Foram excluídos dois por falta de registros completos no prontuário. Do total, 68,7% eram mulheres. A idade variou de 20 a 60 anos, com média de 39 anos. Apenas um caso era associado à síndrome de neoplasia endócrina múltipla tipo 1. Sintomas neuropsiquiátricos, principalmente a síncope, foram os mais comuns. A duração média das manifestações clínicas até o diagnóstico foi de um ano e meio. Exames de imagem foram utilizados em todos os pacientes com 68,7% de localização pré-operatória do tumor. Todas as operações foram realizadas de forma convencional (aberta), sem uso da laparoscopia. As lesões foram identificadas em todas as porções do pâncreas sendo a maioria na cabeça pancreática. O alívio dos sintomas só não foi obtido em um paciente. Não houve óbito entre os pacientes analisados. CONCLUSÃO - O diagnóstico de insulinoma é frequentemente estabelecido após vários meses do início das manifestações clínicas e o tratamento cirúrgico é curativo na quase totalidade dos pacientes.

Solid pseudopapillary tumor of the pancreas: a single-institution 20-year series of pediatric patients

PURPOSE

Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm. The objective of this study was to review our institution's experience and provide an update on current management in the pediatric population.

METHODS

Our pathology database identified all patients with SPT for a 20-year period (1991-2011). Demographics, clinical characteristics, operative details, pathology, and outcomes data were retrospectively reviewed.

RESULTS

Eleven patients with SPT were identified. Most were female and Hispanic. Median age at resection was 14 years (9-17 years). Most patients presented with abdominal pain. Diagnostic imaging was most commonly an ultrasound or computed tomography. All tumors were resected en bloc. Median greatest tumor diameter was 5 cm (3.5-12 cm). Median length of stay was 8 days (5-19 days). Complications included pancreatic leak, chyle leak, delayed gastric emptying, fat malabsorption, and incisional keloid. Recurrence developed after 2.5 years in 1 patient with positive surgical margins. There were no metastases or deaths. Median follow-up was 1.4 years (0.6-5.9 years).

CONCLUSION

This pediatric series of SPT from a single institution corroborates previous reports in the literature. In our experience, SPT behaves like a low-grade malignancy and has an excellent prognosis. Surgical resection is dictated by tumor location and remains the treatment of choice.

Surgical treatment of pancreatic insulinomas

BACKGROUND

Insulinoma is a pancreatic neuroendocrine tumor originated from pancreatic islet beta cells. Although rare, is the most common pancreatic endocrine tumor, with about four cases per million people. The preferential treatment of insulinoma is surgical.

AIM

To analyze the epidemiological, pathological, clinical and surgical patients treated in the last decade in two surgical services.

METHODS

Were retrospectively reviewed the medical records of patients undergoing surgical treatment of insulinoma in the period of 1999 to 2011. Demographic data, type and duration of symptoms, associated or not with endocrine syndrome and diagnostic tests were obtained from medical records. Were analyzed the method of surgery, intraoperative findings and immediate and late complications.

RESULTS

Sixteen patients with insulinoma underwent surgical treatment, 68,7% were women. The age ranged from 20 to 60 years, with a mean age of 39 years. Only one case was associated with multiple endocrine neoplasia type 1. Neuropsychiatric manifestations, mainly syncope, were the most prevalent. The average duration of clinical manifestations until the diagnosis was one year and a half. Imaging tests were used in all patients with 68.7% of preoperative tumor localization. All operations were performed in a conventional (open) manner, without use of laparoscopy. The lesions were identified in all portions of the pancreas with the majority in the pancreatic head. Relief of symptoms was not obtained only in one patient. There were no deaths among the patients.

CONCLUSION

The diagnosis of insulinoma is often established after several months of the onset of clinical manifestations and surgical treatment is curative in almost all patients.

Pancreatic resections for solid or cystic pancreatic masses in children

OBJECTIVES

The aim of the study was to assess the diagnosis and management of solid pancreatic neoplasm in children and the type of surgical treatment, focusing on short- and long-term outcomes.

METHODS

We retrospectively reviewed the charts of all children who had undergone pancreatic resection for suspicion of pancreatic tumor in Kremlin Bicêtre Hospital, Paris, between 1986 and 2008. We studied the symptoms at diagnosis, the type of surgery, and the short- and long-term morbidity and mortality.

RESULTS

Of 18 patients identified, there were 7 pseudopapillary tumors, 3 neuroblastomas, 2 rhabdomyosarcomas, 1 acinar cell carcinoma, 1 endocrine cell carcinoma, 1 renal angiomyolipoma, and 3 pancreatic cysts. Symptoms at diagnosis were abdominal trauma, abdominal mass, and jaundice. Operative procedures were duodenopancreatectomy (11), mid-pancreatic resections (2), splenopancreatectomy (2), distal pancreatectomy (1), and tumorectomy (2). There were no deaths related to surgery. The postoperative morbidity rate was 45%, including 2 cases of fistula (11%) occurring after a mid-pancreatic resection and a pancreaticoduodenectomy. The median follow-up was 4.2 years (range 2-11). There was no diabetes mellitus, but there was 1 case of fat diet intolerance requiring pancreatic enzyme substitution. All of the children had a growth curve within normal limits.

CONCLUSIONS

In this experience, pancreatic resections have proven to be a safe and efficient procedure, with low long-term morbidity, for the treatment of tumoral and selected nontumoral pancreatic masses.

Exocrine pancreatic tumors in childhood in Germany

BACKGROUND

Pancreatic tumors (PT) in childhood are rare. Standard therapeutic approaches are lacking. Our aim was to analyze treatment modalities and outcome in children with PT.

PROCEDURE

Between 1980 and 2007, 55 patients with exocrine PT < 16 years old were registered. Data were obtained from the German Pediatric Tumour Registry. Medical records were evaluated and patient data were pseudonymized.

RESULTS

Patient records of 29 children were available (9 male, 20 female, median age 11.2 years, range 3.1-16). In 18 patients a solid-pseudopapillary tumor (SPT) was diagnosed, in 7 patients a pancreatic carcinoma (P-CA) (5 acinar cell carcinoma (ACC), 2 ductal adenocarcinoma (DCA)), and in 4 patients a pancreatoblastoma (PBL). In 69% of the patients the initial radiological findings led to an incorrect tentative diagnosis. Initial histopathological diagnoses were differing from the reference pathology in 50% of the SPT and 45% of the P-CA. In the group of SPT survival rate was 100%; all patients underwent surgical resection. There were two cases of tumor relapse and one late secondary malignancy of the pancreas (DCA). In P-CA patients, survival rate was 14%, in the PBL group the survival rate was 25%. Concepts of chemotherapy, radiotherapy, and surgical intervention in P-CA and PBL were varying widely.

CONCLUSIONS

In all cases of pediatric PT reference pathology and reference radiology should be involved. Standardized treatment concepts as well as prospective data registrations need to be entrenched.

Surgical treatment of pancreatic tumors in childhood and adolescence: uncommon neoplasms with favorable outcome

BACKGROUND/AIMS

Pancreatic tumors in children and adolescents are uncommon. The aim of the present paper was to analyze short- and long-term outcomes after surgical treatment of primary pancreatic neoplasms in children and adolescents at a single high-volume center for pancreatic diseases.

METHODS

Retrospective review of medical records and pathology reports of patients younger than 18 years who underwent surgery at Verona University Hospital from 1990 through 2010.

RESULTS

The study population consisted of 20 patients. Abdominal pain and palpable mass were the most common presenting symptoms. No patient had a locally advanced, unresectable or metastatic disease. Complete resection (R0) was achieved in 19 patients. There was no postoperative mortality, but postoperative complications occurred in 5 cases (25%). Histological examination showed 12 solid pseudopapillary tumors, 5 neuroendocrine tumors, 2 cystadenomas and 1 epithelial malignant tumor. At a median follow-up of 49.5 months (range: 7-234), there was no tumor recurrence. Postoperative diabetes was diagnosed in 1 patient and 4 other patients developed pancreatic exocrine insufficiency.

CONCLUSION

In the setting of a high-volume surgical center, radical resection of pancreatic tumors in children and adolescents is associated with acceptable postoperative morbidity and favorable long-term outcome.

Pancreatic cystic lesion in an infant

Pancreatic cystic lesions are rare clinical entities. To the best of our knowledge, only 38 cases have been reported in the English literature in children under the age of 2 years. We present a 2-month-old infant with a cystic lesion in the head of pancreas. We reviewed the possible causes and present our dilemmas in the management of these patients.

Pancreatic tumors in children and adolescents: the Italian TREP project experience

INTRODUCTION

Malignant pancreatic tumors are exceedingly rare in pediatric age and their clinical features and treatment usually go unappreciated by most pediatric oncologists and surgeons.

METHODS

From January 2000 to July 2009, 21 patients <18 years old with pancreatic tumors were prospectively registered in the Italian cooperative TREP project dedicated to very rare pediatric tumors.

RESULTS

Tumor types were 4 pancreatoblastomas, 2 pancreatic carcinomas, 3 neoplasms of the endocrine pancreas, and 12 solid pseudopapillary tumors. Three of the four patients with pancreatoblastoma had advanced disease at diagnosis and were given chemotherapy; at the time of this report, three patients were alive in first remission, while one died due to treatment toxicity. Both the cases of pancreatic carcinoma had the acinar cell subtype and successfully underwent pancreaticoduodenectomy with complete tumor resection, remaining without evidence of disease at the time of this analysis. The histological diagnoses of the three endocrine tumors were a malignant islet cell tumor, a gastrinoma, and a well-differentiated tumor. All 12 patients with solid pseudopapillary tumors underwent complete tumor resection and were given no adjuvant treatment; 11 were alive in first remission, while one experienced a local and distant relapse 5 years after diagnosis.

CONCLUSIONS

Surgery remains the keystone of treatment for pancreatic tumors in pediatric age as in adults. The TREP project shows that prospective cooperative studies are feasible even for such very rare tumors as these and may serve as a model for developing international cooperative schemes.

Childhood pancreatic tumors: a single institution experience

PURPOSE

The rarity and histopathologic diversity of primary pancreatic neoplasms in children have made it difficult to predict prognosis and to develop optimal management protocols.

METHODS

A 90-year (1918-2007), single institution, retrospective review of all patients with neoplastic pancreatic masses was performed.

RESULTS

Eighteen patients were identified with 7 distinct histopathologic subtypes. The most common were gastroenteropancreatic neuroendocrine, solid pseudopapillary, and acinar tumors. There were 6 benign and 12 malignant tumors. Six patients had disease outside the pancreas at their initial operation. There were 7 deaths (41%), 2 related to the initial operation, 3 from disease progression, 1 from a small bowel obstruction, and 1 from necrotizing pancreatitis. Five deaths were in patients with extrapancreatic disease found at initial operation. The median duration of follow-up for the 10 survivors was 41 months.

CONCLUSION

In adults, pancreatic ductal adenocarcinoma is by far the most common histopathologic subtype, with other subtypes more common in children. Stage is an important prognostic factor. Long-term disease-free survival in childhood pancreatic malignancies is achievable with complete surgical resection, prognosis, and adjuvant treatment, depending on the histopathologic type.

Malignant Nonfunctioning Neuroendocrine Neoplasm of the Pancreas in a 10-Year-Old Child

Malignant neoplasms of the pancreas are extremely rare in children and only represent a small percentage of pediatric cancer-related deaths. The paucity of cases reported in the literature, in addition to the lack of understanding of biologic behavior, has led to a lack of consensus concerning optimal management strategy. Presentation differs compared to adult counterparts and generally prognosis is improved even when lymph node metastases occur. Here we review the literature and report the case of a 10-year-old autistic female with a malignant nonfunctioning pancreatic endocrine neoplasm of the head of the pancreas successfully extirpated via pancreaticoduodenectomy.

Malignant pancreatic tumors: incidence and outcome in 58 pediatric patients

OBJECTIVE

The purpose of the study was to examine current incidence trends and outcomes for children with pancreatic malignancies.

METHODS

The Surveillance, Epidemiology, and End Results registry (1973-2004) was examined for pediatric patients with pancreatic malignancies (up to 19 years of age).

RESULTS

Malignant pancreatic neoplasms were identified in 58 patients. Females outnumbered males 1.9 to 1 (38 vs 20) for an age population-adjusted incidence of 0.021 and 0.015 per 100,000. Overall, 70% (n = 41) of patients were white. Asians had the highest incidence. Tumors were classified as exocrine (n = 31, 53.4%), endocrine (n = 19, 32.8%), or sarcomas (n = 5, 8.6%). Exocrine tumors included pancreatoblastoma (n = 10), solid-cystic tumor (SCT) (n = 10), ductal adenocarcinoma (DA) (n = 7), and acinar cell carcinoma (ACC) (n = 4). All SCTs and 80% of pancreatoblastomas were seen in females, whereas males had a higher incidence of DA 71% (P = .036). Ductal adenocarcinoma, SCT, acinar cell carcinoma, sarcomas, and endocrine tumors were more common in children older than 10 years, whereas pancreatoblastoma was more common in younger children (P = .045). Almost half of patients (n = 25) presented with distant metastasis; of these, 44% were endocrine tumors. Survival was significantly greater for female patients (P = .004) and for those who had surgery (P = .001) by both univariate and multivariate analysis. There was a significant difference in tumor type 15-year survival with DA having the worst (23%) and SCT the best (100%).

CONCLUSIONS

Pediatric pancreatic neoplasms are uncommon and carry a variable prognosis. Both female sex and surgery were independent predictors of improved survival.

Acinar cell carcinoma versus solid pseudopapillary tumor of the pancreas in children: a comparison of two rare and overlapping entities with review of the literature

Primary epithelial tumors of the pancreas are extremely uncommon in children, and among these, acinar cell carcinoma (ACC) is the most rare. Here we describe our recent observations in the case of a 10-year-old boy with one of these exceptional examples. The histologic diagnosis of ACC was supported by both immunohistochemistry and electron microscopy. Despite its rarity, ACC should be kept in the differential diagnosis of pediatric pancreatic exocrine tumors. We also provide a comparison with an example of solid pseudopapillary tumor, another relatively infrequent epithelial tumor of the pancreas in the young. We review the relevant literature addressing the clinical and pathologic features of ACC and its distinction from other pancreatic neoplasms.

Liver transplantation for multiple liver metastases from solid pseudopapillary tumor of the pancreas

Solid pseudopapillary tumor (SPT) of the pancreas usually shows a benign clinical course. However, sometimes, distant metastasis may occur. Even in such case, the prognosis is good only if metastatic lesions are resected completely. We report the case of a 14-year-old girl with SPT of the pancreas and unresectable synchronous liver metastasis who underwent successful living donor liver transplantation. For 2 years, she has been disease free. This is the first report on transplantation to relieve liver metastasis of SPT.

Hepatic metastasectomy in children

BACKGROUND

There are little data regarding the safety and efficacy of hepatic metastasectomy for solid tumors in childhood. We reviewed our institutional experience to assess operative mortality and morbidity, technique of resection, local control, and survival in pediatric patients undergoing liver resection for metastases.

METHODS

All pediatric patients who underwent hepatic resection for metastatic disease from August 1988 to July 2005 were retrospectively identified and clinical data were collected.

RESULTS

Fifteen patients were identified during this period and primary malignancies included neuroblastoma (7), Wilms tumor (3), osteogenic sarcoma (2), malignant gastric epithelial tumor (1), and desmoplastic small round cell tumor (2). Twelve patients underwent anatomical hepatic resections and 3 had wedge resections. There were no intraoperative or postoperative deaths. The 2 postoperative complications included 1 wound infection and 1 bile collection. The median follow-up after hepatic resection was 1.6 years (0.2-7 years). Three patients remain alive. Eleven patients died of progressive disease; 4 patients suffered local recurrence. One patient died from enterocolitis and sepsis and was without evidence of malignancy at the time of death.

CONCLUSIONS

Hepatic metastasectomy in children is feasible and is associated with a low operative mortality and morbidity. In this small group of patients anatomic hepatectomy was associated with better local control compared with wedge resection. Overall prognosis in these patients remains poor and the decision to perform hepatic metastasectomy should be highly selective.

Central pancreatectomy with pancreaticogastrostomy in children

Children requiring surgical intervention for pancreatic disease may be at risk long term for exocrine insufficiency and glucose intolerance. Pediatric surgeons must balance the need to perform adequate surgical resection while preserving as much normal pancreatic parenchyma as possible. Neoplasms of the middle pancreatic segment with low malignant potential and isolated trauma to the pancreatic body or neck represent 2 conditions where extensive pancreatic resection is unnecessary. Central pancreatectomy for such lesions is well described in adults. Reconstruction of the distal pancreatic remnant is traditionally performed via Roux-en-Y pancreaticojejunostomy. Pancreaticogastrostomy is an alternative approach that has been used to reconstruct the distal pancreas in the adults. Pancreaticogastrostomy offers several technical advantages over pancreaticojejunostomy. Because children may be uniquely susceptible to the long-term consequences of excessive pancreatic resection, 2 cases using this technique of central pancreatectomy with pancreaticogastrostomy are described.

Pancreatic tumors in children: radiologic-pathologic correlation

Pancreatic neoplasms are rare in children and have a different histologic spectrum and prognosis than those in adults. In general, these tumors are well demarcated with expansile rather than infiltrating growth patterns. They may be quite large at diagnosis, and central cystic necrosis is common. They infrequently cause biliary duct obstruction. The imaging appearance of each neoplasm reflects its pathologic features. Pancreatoblastoma is the most common pancreatic neoplasm in young children. At imaging, pancreatoblastomas are heterogeneous and often multilocular with hyperechoic and enhancing septa. Solid-pseudopapillary tumor occurs in adolescent girls. It is heterogeneous in internal architecture, with a mixture of solid and cystic hemorrhagic and necrotic elements. This tumor is distinguished by its fibrous capsule and hemorrhagic nature, which are best shown at magnetic resonance imaging as a dark rim on T1- or T2-weighted images and hyper-intense foci on T1-weighted images, respectively. Islet cell tumors in children are insulinomas or gastrinomas. These tumors manifest early due to hormonal syndromes and are distinguished by their small size, homogeneous appearance, and intense enhancement with intravenous contrast material. All pancreatic neoplasms in children are capable of producing metastases, usually to the liver and lymph nodes; however, on the whole, these tumors have a better clinical outcome than most pancreatic tumors in adults. Knowledge of the differential diagnosis of pancreatic masses in children and their relatively good prognosis may promote correct preoperative diagnosis and appropriate treatment.

[Pancreatic insulinomas]

Insulinoma is the most frequent neuroendocrine pancreatic tumor. In the present study, the clinical and immunohistochemical results of 20 patients who underwent surgery between January 1986 and December 2004 were evaluated. Clinical presentation, laboratory data, imaging studies, aspects of the surgical technique, complication rates and medium- and long-term follow-up were analyzed. Surgical treatment was recommended in all patients based on presenting symptoms and laboratory signs of hypoglycemia and hyperinsulinemia. In 15 patients, the lesion was identified preoperatively. In the 5 remaining patients, intraoperative palpation and ultrasonography were used to locate the lesion. The most frequently performed surgical procedures were pancreatic resection in 10 patients and laparotomic enucleation in the remaining 10. Laparoscopy was used in two patients. Two patients developed diabetes mellitus. The most frequent surgical complication was pancreatic fistula. No mortality was observed in the present series. Symptom reversion, characterized by disappearance of Whipple's triad and normal or increased glycemia values compared with preoperative values, was observed in all patients.

Pancreatoblastoma associated with incomplete Beckwith-Wiedemann syndrome: case report and review of the literature

A case of pancreatoblastoma (PB) in a 2 month-old male infant with incomplete Beckwith-Wiedemann syndrome is presented. Clinical examination disclosed left hemihypertrophy, macroglossia, bilateral exophthalmos, and enlargement of the left testis. Imaging with ultrasound and computed tomography scan showed a well-defined, heterogeneous, and grossly cystic mass arising from the head of the pancreas. Serum alpha-fetoprotein (AFP) level was elevated. The tumor was completely resected, and the histological analysis showed PB. The patient's recovery was uneventful, and AFP returned to normal values after surgery. The child has been disease-free for 5 years, and his serum AFP remained within normal values. Six other examples of this association, PB, and Beckwith-Wiedemann syndrome are recorded in the literature. The risk of developing tumor in this syndrome (complete and incomplete form) increases when hemihypertrophy is present, and the need for routine screening examination is warranted. Beckwith-Wiedemann syndrome was suggested to be a favorable biological marker for survival in children who have intraabdominal tumors.

Relationship between surgical volume and clinical outcome: should pediatric surgeons be doing pancreaticoduodenectomies?

BACKGROUND

The relationship between surgical volume and clinical outcome is well established in adult pancreatic surgery. We examined whether this relationship is applicable in pediatric surgery, given that very few cases are done regularly by pediatric surgeons even at tertiary centers.

METHODS

A retrospective analysis of all patients who underwent pancreaticoduodenectomies between 1993 and 2003 was done. Comparisons were made to the largest recent series of pancreaticoduodenectomies in the adult literature.

RESULTS

With the age at presentation from 9 to 17 years, 5 patients were identified. Mean operative time was 451 minutes with a median of 363 minutes compared with the mean and median in the adult literature of 420 minutes. Clean margins were obtained in all patients compared with 71% in adults. Mean follow-up was 35 months. All patients are alive, with 1 patient who has underwent subsequent resections for local recurrence.

CONCLUSION

Although 5 consecutive cases of pancreaticoduodenectomies represent very low volume compared with high-volume adult centers, minimal difference in operative time, length of stay, and mortality (none) were observed in this series. Therefore, unlike adults, particular case volume in the pediatric population may not be a significant factor because of the nature of pancreatic pathology, patient characteristics, and hospital and surgical environment.

Multidisciplinary management of surgical disorders of the pancreas in childhood

OBJECTIVES

To describe the frequency and range of pancreatic disorders in children requiring surgical intervention and to highlight the importance of multidisciplinary management.

METHODS

An audit of all children under 17 years of age referred with surgical disorders of the pancreas or pancreatitis to a regional pediatric gastroenterology unit in the United Kingdom during a 10-year period. A retrospective chart review of clinical features, pathology and outcome was undertaken.

RESULTS

Surgical intervention was required for the following pancreatic disorders: persistent hyperinsulinemic hypoglycemia of infancy (n = 4), pancreatic tumors (n = 5), pancreaticobiliary malunion (n = 12), pancreatic trauma (n = 6) and pancreatitis (n = 10). The indications for surgery in acute pancreatitis were a persistent pseudocyst (n = 1) and treatment of an underlying cause of pancreatitis (n = 4); in chronic pancreatitis, surgery was used to treat symptomatic pancreatic duct strictures (n = 4). One child died of a progressive lymphoma but all others who underwent surgery are alive and well. All 33 children with acute pancreatitis, including four with pancreatic necrosis, survived.

CONCLUSIONS

Surgery for pancreatic disorders in children is rarely required but may be necessary a) for definitive management of primary pancreatic pathology, b) to treat sequelae of acute or chronic pancreatitis and c) to treat an underlying cause of pancreatitis. There is a broad spectrum of potential pathologies. These patients are best managed by a multidisciplinary team approach.

Mucinous cystadenoma of the pancreas in a one-year-old child

Mucinous cystadenomas of the pancreas are uncommon lesions in adults and even more rare in children. This report presents a case of a pancreatic mucinous cystadenoma in a 1-year-old boy and offers a review of the literature and discussion of the surgical implications.